Monday, February 3, 2014

GUEST ENTRY by KZ, a CRNA. I asked KZ to share some of her thoughts on what might be happening to Jahi's body. This is Part I of a two-part series. Part II will be posted next week, covering three more topics. Sprocket.Jahi McMath: Frequently Asked Questions - Part I by guest writer, KZ

The very sad saga of Jahi McMath continues on. Last week, a Facebook posting put out the information that she is “doing great”, “responds to her mother’s touch”, “healing”, but is “not awake yet.” A brief video clip showing her feet moving was posted, then abruptly pulled off Facebook, but was reposted on YouTube.
1. If those really were Jahi’s feet in the video originally posted on Facebook, how is it possible, if she has brain death, that her feet could move when ice is rubbed on the soles?

Stimulating soles of the feet can produce something called “spinal reflexes”, which are mediated by the spinal cord and peripheral nerves, and does not require higher brain function. Here are some examples.

Changes in spinal reflex excitability in brain-dead humans. The excitability of proprio- and exteroceptive spinal reflexes was monitored electrophysiologically and clinically during the occurrence of brain death (BD) in 8 patients. After a period of total reflex unresponsiveness, the soleus H reflex attained a steady-state excitability level in 2-6 h. The recovery cycle of this response regained its normal shape at 10-20 h.

Digital responses to mechanical stimulation of the foot sole were evident after 6-8 h. It is concluded that the human spinal cord reacts to BD with a spinal shock, characterized by sequential recovery of reflex transmission. The overall timing of this process appears to be much shorter than that previously described for the spinal shock following traumatic transection of the cord, but the latter was never studied in the earliest phases.

If one were to apply a peripheral nerve stimulator to Jahi's body-- the hand and wrist area, for example, it would be quite easy to induce muscle twitching in response to electrical impulses. If you put the stimulator in certain positions, you can even induce a whole joint to flex or contract (like a wrist). This type of stimulation and response is independent of brain function. It would not be a "reaction" to pain, even though someone who isn't knowledgeable might be tempted to interpret it as "withdrawal to painful stimuli."

I think it is probable that Jahi's heart will stop while she is still on the ventilator. I don't see them taking her off the vent, and letting her heart stop. Mrs. Winkfield has said many times that she will not remove the ventilator until her heart stops. And it is definitely possible to have cardiac arrest, and also have a ventilator still cycling and blowing air into her lungs.

If Jahi's heart stops while she is on the ventilator, it depends on "how closely" she is being monitored, how quickly this is detected, and whether or not they have decided to try to do anything about it.

It is "possible" that her heart and other functions (like pulse oximetry) are not being monitored continuously, if she is in a long term care facility. We have no idea what they are monitoring, and the capabilities of the staff and the facility. Particularly if Mrs. Winkfield has decided not to try to do anything medically if her heart enters an abnormal rhythm-- for instance, if she is on palliative care, she may not be on typical ICU monitoring, but just have the ventilator cycling.

If she is receiving heart monitoring and pulse oximetry, and if appropriate alarm limits are enabled and audible, then if her heart enters an abnormal rate or rhythm, the alarms will sound as the limits are violated. Then the staff would have to decide if they are going to attempt to treat whatever is going on (with drugs, and intravenous fluids, and/ or electricity), or "let her go", or call 911, etc. I have no idea what they have decided to do.

If, for example, they have decided to "let her go", hopefully they will silence alarms, allow family to sit quietly with her body, hold her hands, etc, and at some point an appropriate staff member will quietly turn off the ventilator.

Very seldom does a heart go from a normal rhythm to complete stand still (asystole) abruptly-- it's more likely her heart would experience rate and rhythm abnormalities as a prelude to the final pings of electricity that precede asystole (standstill). That could be minutes, or hours. Often, the final bits of electricity can kick out for 15-20 min or more, once a rhythm has ceased. The other situation, is that the heart continues to put out electricity, but there is no "squeeze" to produce a pulse that can be felt. This is called “pulseless electrical activity.” That is a common ending, too, with that rhythm deteriorating to remnants of electricity that eventually stop. PEA is typically only treatable when there is an obvious thing to fix right away—medical folks call these the “Hs and Ts”, from the ACLS algorithms. Otherwise, it’s a sign that the end has come for the function of a heart.

When I was a young nurse in ICU many, many years ago, I was privileged to see a number of hearts “die” on the monitor, in patients on a ventilator, who were “do not resuscitate” status. We had to leave the vent on and cycling until the doc or resident came up and pronounced them dead. Those patients, in their last minutes, taught me a lot of lessons that have helped me anticipate declines in my patients for my entire career. I feel very privileged to have been able to witness those dying hearts, and learn what I was seeing, without the typical hustle and rush of resuscitation.

There is no suffering for someone with brain death whose heart stops. Their color will become pale (most noticeable in the lips and inner mouth, and the palms, in someone with darker complexion), and the skin takes on an ashy or waxy, pale color as circulation ceases.

Jahi’s body wouldn't gasp or convulse.

In fact, if she is not on a heart monitor or a pulse oximeter, the staff might not notice that her heart isn't beating well for quite some time. The vent will continue to cycle, even if her heart isn't beating well enough to circulate blood effectively, or if her blood pressure is very, very low.

I want to add that if she is in a home care, or long term care facility, that the monitors themselves are not as sophisticated as an ICU setting. They may not have any central telemetry monitoring-, but may have a type of transport bedside monitor- meaning, only when someone is in the room looking at her monitor would they be evaluating what is going on. We cannot assume what kind of monitoring her body is receiving, or not receiving, since there is really no "standard of care" for the level of care her body is receiving. Basically, they are free to do whatever monitoring they want, or are capable of doing. I doubt she has continuous arterial blood pressure monitoring, for example-- so may be on intermittent blood pressure cycling using an external cuff (such as a dynamap). They might set that to go off every one minute, or set it to go off every 15 min, or longer, etc. Or just manually cycle the automatic BP when they are in the room.I doubt they have noninvasive cardiac output capability (which uses the ventilator circuit to calculate cardiac output). All of this monitoring is dependent on having staff who understand how to do it, and how to interpret it. We just have no idea what the capabilities are where she is.

While Jahi isn't capable, thankfully, of feeling any distress when her heart stops, the living people around her certainly are capable of feeling distress. Whether or not Jahi's family has a peaceful experience when Jahi's heart stops (which it most assuredly will, at some point), depends on the decisions they have made/ are making about what they want to do when that time comes. From what they have demonstrated over the past 6+ weeks, they are in denial about her brain death, and continue to use social media to proclaim her improvement and that she will fully recover. Perhaps they are saying and feeling differently in their private, family moments together. I'm sure we will never know, nor should we.

If Mrs. Winkfield has decided that Jahi's heart is not a "DNR" (do not resuscitate), they she may have made arrangements with the staff and facility to do whatever they are capable of doing to keep her heart going. That means it could be a very emotional, chaotic situation, as well, if they decided to jump on her chest and do CPR, and attempt ACLS maneuvers. As it has been told that she is in a long term care facility, and given that she is legally dead with a death certificate, it is extremely doubtful 911 would transport to any ER. The capabilities of a nursing home, even one with ventilator and IV capability, are extremely limited, when it comes to providing ongoing "ICU" type support during and following cardiac arrest. They might get her heart back for a few minutes, or a few hours more, but there is a limit to how much you can "flog" a dying heart in a brain dead body.

And keep in mind that if Jahi is in a long term care facility, the capability of the nurses (and physicians) is definitely not the same skill level and knowledge level as that of ICU nurses and pediatric intensivists. In other words, most LTC, LPN's and RN's nurses are very good at what they do, but they are not ICU trained and skilled. They would have a very limited ability to know how to run vasoactive IV drips and monitor them, if they even had access to vasoactive drugs in their facility, etc. Long term care facilities don't have the kind of pharmacy support that acute care hospitals do. There is probably no physician in house 24/7 to tell the nurses what to do (if the doc even knows what to do), beyond BLS, (basic life support) and possibly some ACLS interventions.

What I am getting at is that the stopping of Jahi's heart could indeed be a very chaotic event, and it is also possible that Mrs. Winkfield might "blame" them for not being able to resuscitate Jahi's heart when it happens.

I genuinely hope that the staff "there" is preparing the family for the inevitable, and talking about how to make Jahi's cardiac arrest be as peaceful as possible for the family. I hope this, but I also strongly doubt that anyone is willing to do the intervention with the family that is necessary to get them to the point where they will face reality. Anyone who doesn't speak their party line that Jahi will recover, is summarily dismissed as being "negative", and a "hater", and not trusting God to resurrect her.

All that means is that when cardiac arrest does happen, the family's emotional coping will be hampered even more, and for much, much longer. I wouldn't want to be one of the staff caring for Jahi's body-- I wouldn't trust this family's reactions, based on their conduct over the last 6 weeks. To be continued in Part II, when KZ will address the following questions:

3. Where is Jahi? Could she be in someone’s private home getting care?

4. What kind of care would Jahi’s body need, wherever she is? Is she just laying there like she is asleep? Does she look normal?

5. Are there any odors because she has been dead so long? Is her body decomposing?

28
comments:

Anonymous
said...

i believe the video was the same one taken at CHO that they used to make their case in December.i also believe dolan made them pull it from their site as it was misleading. i did feel symapthy for this family but that is quickly turning to disgust as they continue to abuse a corpse.why do they keep putting a question mark where God has put a period?Cecelia

I agree that the video is likely weeks old, not recent. One of the things that struck me is that the condition of the hydration of her toes is much better than I would expect. Particularly given the condition of the finger tips in a hand holding pic that was posted not too long ago. There have been posters that made a side by side of that pic, with the other hand holding pic the family posted back in early December.

One other thing I wanted to explain is the medical device you can see on her legs in the video, as some might be unfamiliar with it. Those are called "sequential compression devices". They are a kind of leg massager, to help with venous return, and try to prevent blood clots in the legs of people who are bedbound, or have limited mobility.~KZ

Here are 2 examples of a spinal reflex phenomena in brain dead patients. In some patients with brain death, flexion of the neck can produce a flailing effect of the arms, called the "Lazarus Reflex". (Some might find this disturbing.)

I am very curious as to where Jahi's body may be, if she has not already been buried/cremated. I think it would not be too far fetched for her to be at a university medical research/teaching hospital. She could have even been 'admitted' under a fictious name, due to the publicity.Anyone have a thought about this?

Thanks again to all of you that take the time to research and write on this site. I appreciate very much both your time and knowledge. I do have a couple of things I am curious about. When Jahi's heart stops, will the date of death remain as the date on the death certificate? I guess I just have a feeling that the mother will try to fight that date and move it forward to the date the heart stops and I wondered legally if that is something that she could do? The other question is with her date of death being the 12th of December, if the family files a law suit (which I would imagine they will) can Children's be liable for anything that happened after the 12th? I don't know the legal system, but can't comprehend how Children's could be responsible for any improper medical treatment after a patient has died. (like not doing the tracheotomy, or a feeding tube like the family demanded).

I know it would be purely speculation since there is more questions than answers in this case but on what grounds could they sue the hospital? The last article by Dolan said that there would be upcoming litigation against the hospital but if not malpractice, what grounds do they have to file suit?

As selfish as this is, I hope the family does sue the hospital so that we can FINALLY hear the hospital's side of things. Going by hearsay and rumors that have circulated, if there's any truth to them, I don't really think the family stands a chance at winning a lawsuit against the hospital.

Maybe KZ could elaborate but I would think it would be similar to Mrs. Munoz?? I think she was maintained under the best of conditions for the sake of the fetus, correct?? Yet I read an article where her mother said the smell was so bad she could not kiss her child. So very, very sad...

As far as the condition of Jahi's body, of course I have no direct knowledge, so all of this is speculation. In Part 2 of this entry, I have more information about care of the body of a comatose person (which is essentially the same care as someone who is brain dead, except brain dead is more unstable), as well as some thoughts about odors that may be prevalent.

It is extremely likely that her body has lost a lot of weight since Dec 9, 2013, and the loss of the subcutaneous fat, along with altered hydration and circulation to the periphery, may mean that she has some wrinkling, shriveling, or thinning of the finger tips, toes, tip of nose, lips, ears, etc. The mother, in particular, has spoken a lot about Jahi's body's condition in her actions and comments publicly, so I think we can assume the body is being cared for as well as possible.

However, whether she is receiving tube feeds, or IV hydration and nutrition (TPN), her body is in a state of catabolism ("breakdown" of muscle, fat, and tissue) which almost certainly cannot be counteracted with tube feed or TPN. I think she probably looks "okay", but not at all like the pictures of her when she was alive. A lot depends on how much infection she has, in her lungs and elsewhere, and how scrupulous she has received skin care and turning, or if she has a special zero gravity bed, etc.

Sprocket will put up part 2 soon. Thank you to everyone for reading here! ~KZ

That's fascinating, thank you KZ. One thing that puzzles me, and that I would think would be different between a comatose patient and a brain dead body. That is, the functioning of the metabolism, i.e., the ability to digest food and send the caloric content and nutrients to the cells, as I understand it, is controlled and regulated by the brainstem. Comatose patients typically have brainstem function, so their metabolism would generally function normally, correct? As opposed to a brain dead patient, like Jahi, who has no brainstem function, so her metabolism would not be functioning? I.e., her digestion does not work, she doesn't form waste products, etc. Is that right? So, any kind of "feeding", per se, via a g-tube, would just be like running stuff through an inert cavity, wouldn't it? Sorry if this is too morbid, but it is morbidity that we're dealing with, as I understand it...

If she's infected, would the facility really be treating with iv antiobiotics? I've never worked snfs, or outpatient settings, but I would assume they don't have dead stock of antibiotics.

Just like tpn? Are they really running these lines? Aren't the majority of the nurses there, LVNs with limited scope of practice? I know they have certain practice rights if they are working with RNs or MDs but I know as an in patient RN who had a few lvns working with me, they never administered iv therapies. How does it work in a long term care? Hope a snf nurse can chime in.

@smalls777 I have a child with brainstem damage who is TPN-dependent. I can’t comment on a snf, but in a homecare setting LVN’s aren't allowed to access an IV line (at least in California). LVN’s can’t do this level of care in a hospital either, so if it’s not allowed in either of these 2 extremes of care, I can’t imagine that it’s possible in a snf. LVN’s can administer tube feeds.

Ironically, as a caregiver, I access my child’s IV line and I can train others to do so also, but if that person is a nurse, working in a professional capacity, they need to stay within the scope of practice allowed by their license.

@Dave Some terminology clarification… Digestion is the process of breaking food down into smaller molecules (nutrients, etc) that can be readily absorbed or assimilated into the body. Metabolism refers to the process inside of cells where the products of digestion and other small molecules are used to make energy or other materials needed for cell function or somatic life.

Brain death impacts both digestion and metabolism, but both are complex processes and neither is completely regulated by the brain. In both cases, there are number of medical interventions that can be used to replace or circumvent loss of function in brain dead patients.

Very simplified… digestion involves mechanical breakdown of food, chemical breakdown of food and transit of food through the GI tract. An intervention like a feeding tube gets around inability to chew and swallow and transit through the esophagus. The simplest type of feeding tube delivers food into the stomach, but there are more specialized types that allow “food” to be administered directly into the small intestine where all nutrients are absorbed into the blood stream.

Food administered via a feeding tube is usually a special medical formula rather than a puree of whole foods. These are generally at least partially broken down so that no mechanical and very little chemical digestion is needed. Some formulas are so broken down, that are basically fully digested and as long as they reach the small intestine they can be absorbed and used for metabolism.

GI motility is complex – partially regulated by the brain and partially regulated within the GI tract. Brain death results in reduced motility and the processes (oxygen deprivation and the catecholamine “storm” that typically accompanies a cardiac arrest) that occur during acute phases of dying can also damage the portion of motility that is regulated by the GI tract itself. It’s impossible to know how much reduction in GI motility Jahi suffered. The lack of motility can reduce tolerance of tube feeds and increase the possibility of infection.

Total speculation (based on tube and TPN feeding of my own child), but tube feeding into the stomach would probably be risky. A brain dead patient lacks the reflexes that protect the airway and any intolerance of the volume due to could result in aspiration. The next step up in intervention is tube feeding into the small intestine (via GJ tube). If tube feeds aren’t tolerated the GI tract can be completely bypassed - nutrition can be provided via IV line (TPN). Bottom line, it is very possible to provide nutrition to a brain dead patient, but it is very expensive (and potentially risky – TPN associated sepsis is very common).

In my opinion, the metabolic deficits in a brain dead patient are a more significant challenge than the nutritional ones.

Some more reading for those who can manage the medical terminology and concepts:

A very long article on organ transplant, but part of it deals with issues of donor management and support in brain death – both nutritional and metabolic supports (you may need to register with Medscape to read this)

http://www.medscape.com/viewarticle/451208_9

Another article focused on support of pregnant, brain-dead women with discussion of the nutritional and metabolic needs.

SciGeek, thank you very much for that wonderful explanation, and for the supporting links! T & T is very lucky to have a community of readers that is knowledgeable, educated, and willing to share their knowledge.

There is a saying that "one of us is never as smart as all of us together". Thank you to all who read here, and who strive to sift thru the misinformation and hyperbole, and understand the truth of these very difficult situations.

@SciGeek - Thanks so much for the great explanation! That really helps bring into focus the issues that are facing the team that is keeping Jahi's body from decomposing. In other words, if there was not technology available to supplant or "simulate" brain function, the body would simply develop massive infections, i.e., become a bacterial colony. It sounds like the level of care required in this case rises to the level of high tech rocket science, around the clock monitoring and special drugs and nutritive formulations. I guess, once again, the family's argument was that the heart was still beating, so she was still "alive" and that their religious beliefs require them to "protect" that life. At least that's what Paul Byrne is arguing here: Jahi McMath, can you move? "None of these patients with heartbeat, respiration and/or circulation can rightly be called a cadaver or corpse." He has also justified Nailah Winkfield's behavior as "love for her daughter" in the face of attempts of the doctors and the hospital to kill Jahi "Nailah continued to fight for Jahi's life and a legal battle ensued for stay of Jahi's execution. Doctors, the hospital administrator, the hospital's lawyer, spokesperson and consulting physician persisted in their efforts to remove Jahi from the life-sustaining ventilator." For the love of Jahi, the living testimony of Nailah Winkfield I've got to say, this is, in a word, sick. What are these people trying to accomplish? I guess Paul Byrne thinks he's doing God's work to encourage this sick behavior, but to what end? This is utterly incomprehensible to me. At least "Dr." Byrne should realize at some level you can't keep doing this forever. All I can really come up with is that these folks truly, deeply believe that a miracle will happen, and Jahi will come back from the dead. What other reason could there be?

After perusing AllNurses' message board, I took another look at the foot video. Several experienced ICU nurses noted the feet don't look all that great. At first glance I thought the feet looked pretty good. But I looked AGAIN... if you look closely at the left foot (the foot on top of the pillow), you can see a darkening of 3 toes, middle to pinky toe, probably from being on vasopressin. Using vasopressin is a complicated thing because of how the drug works and what it does to peripheral circulation. In order for the body to oxygenate vital organs, including brain (not applicable in Jahi's case), heart, lungs and kidneys, vasopressin causes the circulation in the limbs to be compromised. The situation is similar to that of a diabetic's poor circulation to the feet, causing a toe or the entire foot to become gangrenous and require removal.

Assuming this is the "proof she is alive" video taken around the time of the first court hearings, prior to Dr. Fisher's exam, one can safely surmise the feet, and perhaps by this point, the hands, may well be black and on their way to gangrenous. Jahi's body is being given antibiotics, and while that will "treat" any infection that is a result of the gangrene, it will not correct the circulatory compromise.

Regarding the horrific Lazarus reflex video, according to Jahi's mother during her interview with Piers Morgan, Jahi was "throwing" her arms/hands "up in the air" way back during the December media blitz. The "Jahi is alive" crowd believe this is yet more proof she is alive.

I am grateful that I never had to care for a brain-dead person who was being maintained on a vent. I'd have had nightmares...

@SciGeek - thanks so much for the informative post! (I posted something earlier but I think I messed up proving I'm not a robot). I'm impressed by the technology and the level of care you describe to prolong the inevitable. I can only surmise that the medical professionals who are providing this care (assuming it is still being provided and it is at the level you describe) are doing so out of a profound sense that they are doing a service to the body by providing a chance for a miracle to occur. Their scientific knowledge must surely tell them that their efforts can't result in any positive outcome. I respect those professionals that declined to perform these activities on a corpse because of ethical considerations. Of course, in terms of the treatment that is actually being conducted on Jahi's corpse, and whether it is still being conducted, is total conjecture. It may be that we will never hear from this family again.

I assume, no form of antibiotic will stop the process of infection, eventually. One can only medicate and cure the ailment until the body knows how to morph, change, and defeat the medicine that we use to fight it off.

Do you guys really believe the feet, at this point are gangrenous? If so, what could the mother be possibily thinking?? What excuse can one make for the darkened feet? I'm just baffled if this is still really denial.

Also, thanks to the above poster for responding as a caregiver. I do believe, that as a nurse who teaches home care of certain equipment etc before d/c, that the liability of you performing that specific skill appropriately can and may fall back on the RN educator. Since you are unlicensed, but within appropriate (here in ca) laws, you are allowed to take care of your loved one with appropriate teaching and access to the educators if you run in to a pickle. And I must add, you are such a good soul for being your child's caregiver!! Not a lot of people can do that!

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